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IntroductionThe European Working Time Directive (EWTD) came into force in August 2009 and dictates that junior doctors should not work >48 h on an average week. Many trusts have had to alter on call rotas to be compliant with the directive. Many trainees, particularly in procedure based specialities, have been concerned about the reduction in procedural training. Previous studies have mainly looked at number of hours worked and not the impact on number of procedures performed or new patients seen in outpatients. Our aim was to examine the effect of the EWTD on important training areas; number of colonoscopies performed, number of ERCPs performed and new outpatients seen by gastroenterology trainees.MethodsWorking hours changed from 56 h per week to 48 h per week in February 2009. In our unit, this was delivered by increasing numbers of days off during a full rota cycle without changing individual timetables. Personal logs and local IT systems were examined for 6 months prior to and for 6 months following the change to determine number of new patients seen in outpatients and number of colonoscopies/ERCPs performed. Only three of the trainees attended colonoscopy lists as the fourth post is a hepatology fellowship post and only two of the trainees performed ERCP. Both periods included the same amount of annual and study leave.ResultsFrom August 2008 to February 2009 the four trainees saw 602 new patients and were present at/performed 196 colonoscopies. The two trainees performing ERCP attended/performed 120 procedures during this period. From February 2009 to August 2009 there was a reduction in the number of colonoscopies attended/performed down to 160 (19.4% reduction, p=0.002). There was also a reduction in the number of new patients seen to 456 (24.3% reduction, p=0.01). There was a reduction in the number of ERCPs performed to 104 (13.3% reduction, p=0.1) but this was not statistically significant. Extrapolating these figures to a 5-year training programme, under the 48 h limit trainees would see 730 less new patients, perform 180 less colonoscopies and 80 less ERCPs. Each reductions of these accounts for around a least a year of training.ConclusionThere has been significant impact of the EWTD on training in gastroenterology particularly in colonoscopy training and new patient assessment. ERCP may be impacted however the current numbers are too small. New models of training will be required to address this problem perhaps focusing on post training fellowships.

IntroductionThe differentiation of mucinous from non-mucinous pancreatic cysts is important because of the malignant potential of the latter. EUS-FNA allows for high resolution imaging of pancreatic cysts as well as sampling for markers (CEA), cytology and a visual assessment of cyst content. The Cooperative cyst study found an elevated fl uid CEA (>192 ng/ ml) to be the single most accurate test in correctly predicting mucinous cysts with a sensitivity of 73%. The CEA value of 192ng/ml has subsequently been widely adopted as a defi nitive cut-off value. Methods The aims of the present study were to assess the utility of a cut-off value of 192 ng/ml in differentiating mucinous from non-mucinous pancreatic cysts and to compare this to general EUS assessment. IPMN and mucinous cyst adenoma/adenocarcinoma (MCA and MCAC) were considered separately. The study population comprised all the patients undergoing EUS-FNA at a tertiary centre for assessment of suspected pancreatic neoplastic cysts between June 2003 and April 2010. Results During this period 267 procedures were performed on 235 individuals, of whom 71 had a defi nitive diagnosis (60 resection histology, 5 histology, 6 malignant cytology), cystic degeneration of pancreatic adenocarcinoma (3) being excluded. 68 patients (51 females), (78 procedures) formed the study group. There were 25 mucinous cyst adenomas (11 MCA, 14 MCAC). There were 22 IPMN (2 malignant) and 21 non-mucinous cysts. For MCA/MCAC using a cut-off of 192 ng/ml the sensitivity, specifi city, accuracy and NPV of detecting a mucinous lesion were 62.5%, 94.4%, 79.4%, 73.9%. Combining EUS morphology, cytology and visual assessment of aspirate (mucoid/non-mucoid) gave fi gures of 100%, 70.8%, 86%, 100%. The combination was signifi cantly more sensitive p=0.007, but no signifi cant difference in specifi city. ROC area under the curve was numerically greater 0.861 versus 0.785 (not signifi cant). For the IPMN patients the cut-off 192 ng/ml showed a sensitivity of 20% in the diagnosis of IPMN. EUS diagnosis had a sensitivity of 85%. Sensitivity of aspirate appearance: 87%, cytology: 50%; combining fl uid appearance, EUS and cytology: 93%. Comparing the performance of CEA 192 versus combination in differentiating IPMN from non-mucinous cyst, ROC curve area was 0.864 versus 0.623 p =0.02. Conclusion A CEA cut-off of 192 ng/ml demonstrated good specifi city and moderate sensitivity in the diagnosis of MCA, however it performed poorly in the diagnosis of IPMN. Combining EUS, aspirate appearance and cytology was signifi cantly more sensitive in diagnosing mucinous cysts with a very high NPV. Competing interests None.

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